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Jurnal English Covid.2
Jurnal English Covid.2
Jurnal English Covid.2
Affiliations:
Corresponding author:
Luca Simione
Tel.: +39-06-44595246
E-mail: luca.simione@istc.cnr.com, luca.simione@gmail.com
Orcid ID: 0000-0003-1938-8466
Abstract
In this study, we investigated the perception of risk and the worries about COVID-19 infection in both healthcare
workers and general population in Italy. We studied the difference in risk perception in these two groups, and how this
related to demographic variables and psychological factors such as stress, anxiety, and death anxiety. To this aim, we
administered an online questionnaire about COVID-19 together with other questionnaires assessing the psychological
condition of participants. First, we found that the exposition to infection risk, due to living area or job, increased the
perceived stress and anxiety (i.e. medical staff in North Italy was more stressed and anxious respect to both medical-
and non-medical participants from Center and South Italy). Then, we conducted hierarchical logistic regression models
on our data to assess the response odds ratio relatively to each predictor on each dependent variable. We found that
health workers reported higher risk perception, level of worry, and knowledge as related to COVID-19 infection
compared to general population. Also psychological state, gender, and living area were important predictors of these
factors. Instead, judgments about behaviors and containment rules were more linked to demographics, such as gender
and alcohol consumption. We discussed these results in the light of risk factors for psychological distress and possible
interventions to meet the psychological needs of healthcare workers.
Keywords: healthcare workers, risk perception, worry, COVID-19, coronavirus outbreak, distress, mental health,
physicians, doctors, nurses.
1. Introduction
On December 31, 2019, some cases of pneumonia of unknown etiology have emerged in the Hubei region of China.
Then, on January 7, 2020, the causative agent has been identified by means of oropharyngeal swabs, i.e. a virus
belonging to the Coronaviridae family called SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2). This
new coronavirus was responsible of the respiratory syndrome called COVID-19 (World Health Organization, 2020).
Most of the patients with positive swab test developed only minor symptoms, such as fever, dry cough, and pharyngitis,
with a benign evolution and spontaneous resolution of the clinical picture. However, some patients developed severe
complications, such as interstitial pneumoniae with acute respiratory distress syndrome, pulmonary edema, multi-organ
failure, septic shock, and even death (Sohrabi et al., 2020). Patients at risk were in particular males, aged over sixty,
suffering from cardiovascular comorbidities (e.g. arterial hypertension, diabetes, chronic coronary artery disease),
affected by chronic pneumopathies or cancer (WHO, 2020; Zhou et al., 2020).
In the following month, the disease spread to other countries outside China, including Italy, where the first
positive cases were found on February 21, 2020; Spina et al., 2020). Italy experienced a significant increase in new
cases, mostly in the month of March, in particular in the North regions, and this caused in turn a growing alarm
throughout the Italian medical-hospital sector due to the imbalance between the resources of the national health system
(indicated as SSN, i.e. ‘Sistema Sanitario Nazionale’) and the expected need for treatment required by the forecast on
the spread of the virus. This concern was publicly expressed in the guidelines published by the Italian Society of
Anesthesia, Analgesia, and Intensive Care (named SIAARTI, i.e. ‘Società Italiana Anestesia, Analgesia, Rianimazione
e Terapia Intensiva’) on March 6, 2020, which reported that in case of huge imbalance between the real clinical needs
of the population and the effective availability of intensive resources, medical doctors should select patients for
intensive therapies basing on their actual hopes of survival (SIAARTI, 2020). In fact, in Italy there were about 5200
beds in total for intensive care units, and that on March 11, 2020, 1028 of these beds had already been destined to
patients suffering from COVID-19. According to the predicted number of new cases, the peak of contagions would be
reached by mid of April, when at least 4000 beds in the ICU (Intensive Care Units) would be needed in order to treat
patients with COVID-19 (Remuzzi & Remuzzi, 2020), with significant consequences also for patients not affected by
COVID-19, who would have less availability of assistance in the aforementioned units.
However, while on the one hand doctors and other health workers multiplied their alarms relatively to this
critical situation and to the related recommendations regarding behaviors to be followed and the hygienic conduct to be
implemented, on the other hand there were daily episodes of violation of such medical recommendations by the
population, apparently only scarcely aware of the problem. For this reason, i.e. the failure of the unanimous
spontaneous compliance of the population to the proposed hygienic rules and health practices, since February 23 the
Italian Government implemented increasingly restrictive dispositions to limit the spread of the disease throughout the
country with various Prime Minister Decrees (named DPCM, i.e. Decreto del Presidente del Consiglio dei Ministri) (see
DPCM on February 23, March 1, March 4, March 8, March 9, and March 11, 2020). In fact, a significant portion of
population continued to engage in risky behaviors, prompting increasingly stricter rules emanated by the authorities.
Therefore, a gap appeared to emerge between the indications and requests from the national health system staff and the
reception of these same indications by the population, as well as a general difference in the perception and evaluation of
the risks associated with the COVID-19 infection between the two groups. Such a difference seemed more evident
especially in the areas of central and southern Italy, where the COVID-19 spread was at that moment less important
than those of northern Italy, as reported by the daily data provided by the national civil protection (see Cereda et al.,
2020).
The spread of the SARS-CoV virus in 2002 has shown how this type of epidemic disease has important
psychopathological consequences, in the short and long term, in particular on health workers (Lung, Lu, Chang, & Shu,
2009; Maunder, 2009; Sim & Chua, 2004). Thus, in the actual spread of the new SARS-CoV-2 virus attention to
psychological health of doctors and others healthcare workers had already been expressed regarding the Chinese
situation relating to COVID-19 (see for example Xiang et al., 2020), with proposals for intervention and support from
the hospital structures (Chen et al., 2020). In fact, Chinese health workers in Wuhan faced a situation characterized by
poor safety and protection, with excessive workloads, high infectious risk in the absence of adequate personal protective
equipment (PPE), and shortage of staff. This risky situation for one's own and loved ones' health could have clinical
consequences, but also psychic ones. In fact, these health workers showed a symptomatology characterized by tiredness,
worry, fear, frustration, isolation, depression, anxiety, stress, insomnia, anger, and negation (Kang et al., 2020). In
particular, in this group of workers, women, workers with over 10 years of service and operators who had a history of
past psychological suffering showed higher risk of stress, anxiety and depression (Zhu et al., 2020).
A further risk factor for psychological distress could be a reduced social network support, as it increases the
resilience to stressors (Ozbay et al., 2007). In the emergency situation caused by SARS-CoV-2, healthcare workers are
indeed at high risk of acute stress, and this risk could be even higher if they feel such a disjunction from the social
community formed by the other citizens, as the current situation in Italy seems to lead. In addition to the personal
consequences on the psycho-physical health of the health professionals, this could easily lead to a progressive decline in
their health services, with a worsening of the quality of care provided. The experience with the disease caused by H1N1
in Japan showed how policies that take care of healthcare and give physicians confidence positively affected the overall
care they provide to the population (Imai, 2020; Maunder, 2009). For all these reasons, it is very important to study the
trait and state psychological variables of healthcare workers as risk or protective factors respect to the actual stressful
situation. In this manner, it would be possible to evaluate the analogies and the differences with the Chinese model at
both intra-cultural and inter-cultural level (McCrae, 2001), for considering which intervention strategies could be suited
for Italian healthcare workers and thus importing the most adequate recently developed for the Chinese healthcare
system in response to the spread of COVID-19.
In such an emergency situation, characterized by contrasts between the opinions and the worries of medical
doctors on one side and the behaviors and the attitudes of general population on the other, we designed and conducted
this study. On the basis of the evidences reported above, our objectives were i) to probe the opinions and the worries
relative to COVID-19 spread in both general population and healthcare workers, ii) to study which demographic,
geographic, and psychological variables were related to a higher perception of the health risks, and lastly iii) to assess
any difference in risk perception relatively to COVID-19 between general population and healthcare workers. Thus, our
aim was to understand the influence of psychological and training/working experience in shaping opinions, worries, and
risk perception relatively to COVID-19. To this aim, we administered an online battery including a questionnaire about
the direct experience, the opinions and the worries relative to the COVID-19, and some questionnaires evaluating the
psychological distress state. To evaluate the distress level of participants, we administered questionnaires measuring
perceived stress, anxiety, and death anxiety as they usually increased in general population (Brooks et al., 2020) and in
healthcare workers (Brady, 2015; Kang et al., 2020) during emergency situation. As the social-health situation in Italy
was evolving continuously in the beginning of March, we limited the data collection in the days 10-12 March 2020.
2. Methods
2.1. Participants
Three-hundred fifty-three Italian adults participated to this study (mean age=38.26 years, SD=12.24 years; female=265,
males=88). We divided our sample by means of their job or training: in the first group we included medical doctors,
nurses, paramedics, students in medicine/nursing/other medical disciplines (‘MED’ group; N=167; mean age=35.56
years, SD=9.90 years; female=133, males=34), whereas in the second group we included all the remaining participants
(‘CONTROL’ group; N=186; mean age=40.69 years, SD=13.58 years; female=132, males=54).
Table 1 reported the descriptive statistics for the two groups and the relative tests for samples’ comparison. As shown,
participants in the MED group were younger (M=35.56 vs M=40.69), studied more years (M=23.02 vs M=21.34), had
less children (M=0.40 vs M=0.58), reported to sleep in average less time per night (M=6.84 vs M=7.06), and were more
frequently vaccinated for annual flu in 2019 (40% vs 13%).
Table 1. Descriptive statistics computed overall the sample and for the two groups separately.
Sleep hours per night 6.96 0.92 6.84 0.94 7.06 0.89 t(351)=2.24*
N. of cigarettes per day 2.20 4.77 2.11 4.49 2.27 5.03 t(351)=0.32
Italy area
1.2. Procedure
We recruited our participants with a convenience sample method via email and social media. Participants received a
brief description of the study together with an informed consent module. After providing informed consent, they
completed an online battery of questionnaires, as described afterwards. Data were collected in anonymous format, and
participants were invited at the end of the battery to leave their email in order to be contacted for possible follow-up
measures. In this study, we collected data not reported here.
1.3. Materials
In this study, we administered questionnaires to evaluate the psychological condition and personality traits of each
participant. Where possible, we opted for short or brief version of each questionnaire, in order to contain the total
number of items (45 total items). We included in our battery, among others, the following questionnaires:
• The 4-item Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 2006), a questionnaire evaluating
the stress perceived by the participant in the last month, i.e. the participant’s perceived feeling to be in control
over external events, relationships, and emotional life. We used the short 4-item version. Each item was
evaluated on a 5-point Likert scale ranging from 0 (never) to 4 (very often).
• The 6-item version of State-Trait Anxiety Inventory (STAI; Marteau & Bekker, 1992), which assessed the
anxiety of the participants on 6 items including emotions or feelings. Each item was evaluated on a 4-point
Likert scale ranging from 1 (almost never) to 4 (almost always).
• The death anxiety scale of the Existential Concerns Questionnaire (ECQ; van Bruggen et al., 2017) which
evaluated the anxiety of the participant relatively to his or her sense of finitude, to the fear of diseases and
death. The total score was computed overall 5 items. Each item was evaluated on a 5-point Likert scale ranging
from 0 (never) to 4 (always).
• The Marlowe & Crowne social desirability scale (M&C; Manganelli Rattazzi, Canova, & Marcorin, 2000),
which assessed the tendency of answering in a socially desirable manner. This version of the scale implied 9
items evaluated over a 6-point Likert scale ranging from 1 (absolutely false) to 6 (absolutely true).
We also developed a questionnaire about SARS-CoV-2 and COVID-19-related experience and personal opinion.
Both authors LS and CG compiled a first list of items; then this list was revised by five experts (medical doctors and
psychotherapists) in order to remove, change or add relevant items. We obtained a final list including 68 items. A
complete list of the items was reported in Appendix A. To keep the questionnaire simple and easy to understand, we
preferred to include mostly yes/no questions. The questionnaire we administered included:
• Demographic and personal information, i.e. age, gender, living in which part of Italy (North, Center, or South),
years of study, job, relationship status, number of children, if pregnant or with a pregnant partner, number of
cigarettes per day, alcohol drinking, presence (and type) of a chronic disease or other pre-existent illness, drugs
taken, religious belief, and if vaccinated for flu in 2019;
• Direct experience with the COVID-19 infection, i.e. if tested with the swab, if positive, if experienced COVID-
19 symptoms;
• Preoccupation about infection, at personal, family, and society level;
• Opinion about personal and other people’s behaviors since the COVID-19 breakthrough;
• Opinion about the containment measures adopted by Italian Government;
• Information received about the disease and the social situation relative to the breakthrough of COVID-19.
3. Results
3.1 Experience with the COVID-19
In this first results section we reported the analysis of the data relatively to the experience with the COVID-19. We thus
referred to the data in the first part of the questionnaire, in which we asked if participants had personal experience or
contact with COVID-19 infection. We reported data overall participants and divided by groups in Table 2. Frequencies
were compared by means of chi-squared test within each group (or overall sample) with the independent variable of
zone.
For the overall sample, we found an effect of the living area on: question 3, about the presence of symptoms
related to COVID-19, χ2(2)=44.48, p<.01; question 4, about thinking that the symptoms relate to a COVID-19 infection,
χ2(2)=11.64, p<.01; question 6, about the quarantine status, χ2(2)=30.67, p<.01; question 7, about contact with people at
risk of infection, χ2(2)=21.87, p<.01; question 9, about the presence of positive case in the living area or city,
χ2(2)=132.71, p<.01. In answering to all these questions, participants from North Italy reported greater direct experience
with COVID-19 than participants from Center or South Italy, whereas participants from Center reported more personal
experience than participants from South.
Then, we compared the frequencies overall areas between the two groups, MED vs CONTROL. We found
significant differences in the question 7, about contact with people at risk of infection, χ 2(1)=14.41, p<.01, and in the
question 8, about contact with people positive for COVID-19 test, χ2(1)=20.01, p<.01, with participants in MED group
reporting more frequent contacts with people at high risk of infection or already positive. Comparing the frequencies
reported in each area within each group, we found the same pattern of results we found for the overall population, with
significant differences in both MED and CONTROL group for question 3, 4, 7 and 9. In all these cases, participants
from North Italy reported more frequent experience with the new coronavirus.
Table 2. Frequency (in %) of “yes” response to each question, computed by area and by group.
N° Question Center North South Center North South Center North South
Have you done a throat
1 0.00 3.13 0.00 0.00 5.26 0.00 0.00 0.00 0.00
swab for SARS-CoV-2?
2 If yes, was it positive? 0.00 1.56 0.00 0.00 2.63 0.00 0.00 0.00 0.00
Do you or have you
recently had one or more
3 36.94 42.19 40.30 36.96 50.00 43.24 36.92 30.77 36.67
symptoms related to
COVID-19?
If yes, did you think could
4 6.76 18.75 1.49 9.78 18.42 2.70 4.62 19.23 0.00
be COVID-19?
If yes, have you alerted the
5 2.70 7.81 0.00 4.35 5.26 0.00 1.54 11.54 0.00
national health service?
Are you currently or have
you been on spontaneous or
6 22.97 31.25 17.91 20.65 28.95 10.81 24.62 34.62 26.67
imposed quarantine for
COVID-19?
Are you currently or have
you recently been in contact
7 22.07 53.13 17.91 34.78 60.53 29.73 13.08 42.31 3.33
with people at high
infectious risk?
Are you currently or have
you recently been in contact
8 with people who had a 4.05 14.06 2.99 9.78 23.68 5.41 0.00 0.00 0.00
positive test for COVID-
19?
Have any positive cases of
COVID-19 infection been
9 88.29 98.44 68.66 90.22 100.00 78.38 86.92 96.15 56.67
detected in your living area
or city?
N. total 222 64 67 92 38 37 130 26 30
Figure 1. Average score for ECQ (left panel), PSS (middle panel), and STAI (right panel) plotted by group (MED vs
CONTROL) and area (North, Center, or South). Average scores for each combination of group and area are reported
on top of the bars.
Do you think you are currently at infectious risk? 0.57 0.71 0.45 5.72* 1.67* 0.99 0.43** 0.60 0.88 0.90 0.80 0.89 1.10* 0.96 1.01 2.72**
Did you think you were at risk when the first cases
0.18 0.23 0.14 2.25 1.05 1.02 0.43* 0.40* 0.68 1.32 1.17 0.57 1.10 0.99 1.04 1.88*
appeared in Italy in January 2020?
Do you think your family members/loved ones are
0.65 0.73 0.57 1.12 1.65+ 0.96** 0.65 1.21 1.10 0.87 1.03 0.67 1.05 1.03 1.00 1.61+
currently at infectious risk?
Are you worried about the possibility that, in case of
0.57 0.59 0.55 0.08 2.98 1.03* 1.66 1.16 0.93 2.26** 0.99 0.87 1.06 1.03 1.15** 1.35
infection, you may have serious complications or die?
Are you worried about the possibility that, in case of
infection, some of your family/loved ones may have even 0.93 0.95 0.92 0.51 2.19+ 0.99 0.01 0.01 2.61+ 1.43 0.70 1.90 0.96 1.07 1.09 1.16
serious complications or die?
Are you worried about the possibility that the situation
may precipitate at global level in the near future due to 0.73 0.76 0.70 0.03 2.03** 1.02 0.79 1.19 1.08 0.91 1.10 0.80 1.08 1.05 1.06* 1.32
COVID-19?
Are you worried about the possibility that, if the national
health system was unable to guarantee treatment or to
support the volume of hospitalized patients, episodes of 0.83 0.86 0.81 0.17 1.58 0.98+ 0.82 1.19 1.70 0.65 0.90 2.29* 1.09 1.14* 1.03 1.45
violence and abuse may occur among patients or their
families?
Are you concerned about the possibility that other
people’s behavior in response to this situation could be
0.83 0.86 0.81 0.12 1.01* 0.95** 0.93 0.98 1.01 0.89 0.86 0.69 1.06 1.01 1.00 0.99
more dangerous than the medical risks associated with
COVID-19 infection?
If you work in the medical/health sector, do you fear that
the scarcity of means and resources of care foreseen for
the near future could expose you to episodes of violence 0.73 0.73 - - 1.01 0.99 0.55 1.13 1.10 1.33 0.93 0.87 1.02 1.07 1.05+ -
or retaliation by patients or their families? (answer “no” if
you are not a doctor/other health worker)
Do you think you might have put yourself at risk of
0.18 0.23 0.15 1.86 1.68 0.97* 0.60 0.50 0.70 0.82 1.05 0.95 1.09 0.96 1.03 1.35
infecting yourself with your behavior?
Do you judge the current containment action as adequate? 0.56 0.51 0.61 3.96* 0.86 1.01 2.23** 2.90** 1.15 0.65+ 0.89 1.44 0.96 0.99 0.99 0.75
Are you currently limiting your risky behavior? 0.99 1.00 0.97 0.56
According response
(to ‘equal’ reference)
Spread of the virus will slow down in the next few days 0.35 0.19 0.45 15.36** 1.33 1.04+ 0.64 1.09 0.64 1.44 0.74 2.78* 0.97 1.01 0.97 0.28**
Spread of the virus will accelerate in the next few days 0.73 0.75 0.72 0.53 1.34 1.01 0.66 0.90 1.01 0.93 0.71+ 1.12 0.97 1.04 0.96 1.20
Spread of the virus will slow down in the next few weeks 0.75 0.71 0.78 5.49* 0.99 1.00 1.06 1.63 0.70 0.55+ 0.88 1.82 0.84* 1.09 1.03 0.71
Spread of the virus will accelerate in the next few weeks 0.71 0.73 0.69 1.07 1.61 1.00 1.20 1.77 0.59 0.99 0.97 1.10 0.84* 1.18** 1.02 1.43
Note. Questions in italic showed imbalanced responses (almost all "yes" or "no"). Gender was coded as 0=male, 1=female. Relat.=In a relationship; Relig.=Catholic or other
confession; Alc.=Alcohol consumption (on a scale from 1 to 4); Public trans.=Using public transportation for moving; ECQ=death anxiety; PSS=perceived stress; STAI=trait
anxiety. Sig. level marked as + p<.10, * p<.05, ** p<0.01.
4. Discussion
In this paper, we investigated the worries and the perception of risk towards the health and social situation in Italy
related to the outbreak of COVID-19. To this aim, we conducted a cross-sectional study by means of online
questionnaires administered to a convenience sample of volunteer participants including both health workers and
general population. We asked to participants to report their worries and opinions about COVID-19 in about 50 different
questions combined with psychological variables measuring stress, anxiety, and death anxiety. We obtained and
analyzed data from three-hundred fifty-three Italian adult, divided in 167 participants in the MED group (medical
doctors, paramedics, health workers and students) and 186 participants in the CONTROL group. We mainly compared
the answers given to the questionnaires by these two groups. We also investigated the effect of the living area in Italy,
as the northern regions were more involved than the central and southern ones (Cereda et al., 2020).
Acknowledgments
We would like to thank all participants to our study, who voluntarily donated their time. In particular, we thank
healthcare workers, whose time is even more precious in this difficult situation for all the country, who participated and
distributed the questionnaire to their peers and colleagues, Finally, we would like to thank our colleagues and friends
Martina Formisano, Alessio Montemagno, Antonello Catinari, Francesco Romano, Elisabeth Prevete, and Salvatore
Chiarella for their valuable help and sustain.
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Appendix A
Table A. COVID-19 Questionnaire questions in Italian (as presented to participants) and translated in English.